Health inspection·December 30, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3(Resident #19, Resident #4, and Resident #22) residents reviewed for infection control. The facility failed to have signs to acknowledge EBP for rooms [ROOM NUMBER] needed for PPE. This failure had the potential to result in staff not following appropriate PPE, increasing the risk of transmission of infectious organisms. Findings included: On 12/30/2025 at 9:45 am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room. On 12/30/2025 at 9:48am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room.On 12/30/2025 at 10:02am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room. Record review of Resident #19's undated face sheet revealed he was a [AGE] year-old male with an initial admission date of 04/17/2016, with the most recent admission on [DATE]. Resident #19 had diagnoses of obstructive and reflux uropathy (when urine cannot drain through the urinary tract) and malignant neoplasm of left kidney (kidney cancer). Record review of Resident #19's care plan dated 12/30/2025 reflected the focus for EBP was that staff must use gowns and gloves during high-contact resident contact care activities that could possibly result in transfer of MDROs to hands and clothing of staff. The interventions stated a sign for EBP precautions will be outside residents' room to alert staff of precautions with direct care procedures. Record review of Resident #4's undated face sheet revealed she was a [AGE] year-old female with an initial admission date of 06/04/2025, with the most recent admission on [DATE]. Resident #4 had diagnoses of sepsis (infection in the body), slow transit constipation, and anemia (lower than normal red blood cells). Record review of Resident #4's care plan dated 06/05/2025 revealed the focus for EBP was that staff must use gowns and gloves during high-contact resident contact care activities that could possibly result in transfer of MDROs to hands and clothing of staff. The interventions stated a sign for EBP precautions will be outside residents' room to alert staff of precautions with direct care procedures. Record review of Resident #22's undated face sheet revealed he was a [AGE] year-old male with an initial admission date as 07/31/2025. Resident #22 had diagnosis of heart failure. Record review of Resident #22's care plan dated 08/01/2025 revealed the focus for EBP was that staff must use gowns and gloves during high-contact resident contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff with no interventions. During an interview with LVN M on 12/30/2025 at 10:05am, she stated there is normally a note on the door and she has been in-serviced on precautions within the last 60 days. If the equipment is on the door, use sanitizer before entering the room. If the equipment is in bins outside of the room, they must use gowns, Residents Affected - Few Page 1 of 2 675789 675789 12/30/2025 Avir at Arden Wood 8810 Long Point Dr Houston, TX 77055

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gloves, and masks before entering the room. If the signage is not on the door, she would contact the nurse or the infection control preventionist. During an interview with LVN E on 12/30/2025 at 10:09am, she stated the last in-service for PPE was a few weeks ago. It would depend on what the resident has going on to determine if PPE is needed, but the EBP signage will confirm what is necessary before entering the room. If there is no signage, she would confirm with the infection control preventionist, due to the risk of infection spreading. During an interview with CNA Y on 12/30/2025 at 10:27am, stated before entering the room, the signage will be on the door to clarify if the staff use sanitizer before and after visiting with the resident, who is not on contact. If there are three bins by the door, staff is to use all equipment before entering the room, such as mask, gloves, and gown which indicates the resident is on contact. If the signage is missing, she would speak with the nurse to confirm what is needed before entering the room. The last in-service for EBP was a month ago. The risk of the signage missing is not protecting the resident and herself from infection. During an interview with ADMN on 12/30/2025 at 10:52am, the ADMN said the facility staff discuss anyone in isolation to know who is on EBP and what equipment is needed prior to entering the room. The facility's procedure for EBP is to decide if the equipment is hanging on the door, use sanitizer or wash hands and if there is a bin outside the room door, use everything for isolated residents to protect the residents and staff from possible risk of infection. During an interview with RN C on 12/30/2025 at 11:42am, RN C, who is the facilities infection preventionist, stated the EBP signs have been missing and she does replace them at least once a week. There was an in-service in the month of December on EBP and contact for all staff. She has been replacing EBP signs at least once a week, because they have been disappearing. The residents with missing signage, are not on contact and she clarified the residents are on EBP due to their diagnosis. Before staff or any visitor enter a resident room for isolation there is equipment in a bin outside of the door for gloves, mask, and gown to be put on prior to entering the room. For residents with EBP, if the resident is not touched, it is safe to go in the room. If the sign is missing, the staff/visitor should check with the charge nurse, ADON, or infection preventionist. The risk of no signage on the door is a chance of infection for the residents or staff because the PPE is used to protect the residents from staff. During an interview with CNA J on 12/30/2025 at 1:30pm, CNA J stated EBP is known by the isolation cart outside of the room for PPE usage before entering the room. If the resident is not in isolation, there will be PPE on the door, which is necessary if they need to touch the resident or have any type of physical contact. If the sign is missing, she would check with the charge nurse, ADON, and Infection Preventionist on how to proceed before entering the room. The last in-service for EBP and isolation was a few weeks ago. The risk of the signage not being on the door is infection, bacteria, and transmitting. On 12/30/2025 at 1:57pm it was observed that all rooms needed for EBP had signage on the door. Record review of an in-service dated 10/25/2025 for EBP for contact vs. EBP. It read as. contact requires the box isolation cart (strict) EBP has the hanging equipment on the door. EBP is precautionary. Signage on door for EBP and contact isolation precautions. The in-service was completed by RN C and signed by all staff. Record review of the facility's policy for Enhanced Barrier Precautions, dated for March 2024. EBPs are indicated (when contact precautions do not otherwise apply) for resident with wound and/or indwelling medical device regardless of MDRO colonization.11. Signs are posted in the door or wall outside of the resident room indicating the type of precautions and PPE required. 675789 Page 2 of 2